The document provides a morning report on a fever of unknown origin case. It summarizes: 1) A 58-year-old male presented with prolonged fever for 1 month despite previous antibiotic treatment for presumed typhoid fever. He had weight loss and decreased appetite. 2) Physical exam was normal but labs showed leukocytosis, increased CRP, and hyponatremia. Imaging found hydronephrosis and nephrolithiasis. 3) Differential diagnoses for the fever of unknown origin were discussed, including further diagnostic tests needed to establish a diagnosis. Control of diabetes and urology follow-up were also mentioned.

1. MORNING REPORT:
FEVER OF UNKNOWN ORIGIN
Jessica Putri Natalia S
RESOURCE PERSON:
Dr. dr. Soroy Lardo, SpPD
DEPARTMENT OF INTERNAL MEDICINE
RS KEPRESIDENAN RSPAD GATOT SOEBROTO
JUNI 2017

2. IDENTITY
Name : Tn. PP
DOB/Age : February 28th 1959/ 58 years old
Religion : Christian
Marital Status : Married
Address : Jalan Tengki No 22 RT 004/06 Cipayung, Jakarta
Medical Record : 855989
Admission : June 7th 2017
Ward : PU lantai 4

3. CHIEF COMPLAINT
Prolonged fever since 1 month before hospital admission

4. HISTORY OF PRESENT ILLNESS
 Since 1 month before admission, patient has been experiencing
fever, history of fever at particular time of a day is denied, highest
temperature recorded might reach up to 39-40◦C, subsided with
paracetamol administration.
 No history of cough, nor shortness of breath, normal micturition
and defecation.
 History of travelling to malaria-endemic-regions was denied.
 Decreased appetite since 1 month before hospital admission. Patient
admitted weight loss over the course of 1 month due to decreased
appetite, however couldn’t point out how many kilograms he had
lost. Patient also complained feeling nauseous during meal without
history of vomiting.
1 month before admission

5. HISTORY OF PRESENT ILLNESS
 Patient had sought medical assistance by polyclinic visit, ran blood tests and
was diagnosed with typhoid fever. Patient was then given antibiotics for
typhoid fever, however he never fully recovered
• Patient went to Rumah Sakit Pondok Indah for his prolonged fever. Several
blood tests were carried out and was performed abdominal USG dan
urology CT-Scan.
• Patient was diagnosed with enlarged right kidney and multiple kidney stones.
1 month before hospital
admission
I week before admission

6. HISTORY OF PRESENT ILLNESS
 Patient was recently diagnosed with type II diabetes mellitus in 2017.
Patient takes Metformin 2x500mg regularly.
 History of hypertension was denied.

7. HISTORY
History Of Past Illness
• Patient was diagnosed with
coronary heart disease, was offered
CABG since there were 4 occluded
arteries (?) but refused.
• Patient regularly takes:
• Aspilet 1x80 mg
• Bisoprolol 1x5 mg
• Amlodipine 1x5 mg
• Simvastatin 1x20 mg
• Patient hardly ever experienced any
chest pain episode
• History of TB was denied
History of Family Illness
 No history of hypertension, nor
diabetes, nor heart disease, nor
malignancy
 Social History
Patient used to be an active smoker
in younger age
Patient works as “wiraswasta”

8. PHYSICAL EXAMINATION
(ON PRESENTATION)
Vital Signs
BP : 144/84 mmHg
HR : 76x/min, regular,
adequate
RR : 18x/min, torakal
T : 37 ◦C
BW : 55kg
Height : 168cm
IMT : 19.48 kg/m2
(normoweight)
General Status
 Conciousness: Compos
mentis
 General condition: mildly ill

9. PHYSICAL EXAMINATION
 Skin : within normal limit
 Head : normocephal, no coated tongue
 Hair : greyish black hair, hair can’t be plucked easily
 Eyes : no pale conjunctiva, no icteric sclera
 Neck : no lymph node enlargement, JVP 5-2 cmH2O

10. PHYSICAL EXAMINATION
Lung
Inspection : Symmetrical on
insipiration and expiration
Palpation : symmetrical fremitus
Perkusi : Sonor on both lungs
Auskultasi: Vesicular, no wheezing,
no rales
Heart
Inspection : ictus cordis can’t be
located
Palpation : ictus cordis palpable
on 1 finger medial to linea
midclavikula sinistra, thrill (-),
heaving (-), lifting (-)
Percussion : heart borders within
normal limit
Auskultasi: regular S1 S2, no
murmur, no gallop

11. PHYSICAL EXAMINATION
Abdomen
Inspection : flat stomach
Palpation : supple, no pain on palpation, no liver or spleen enlargement
Perkusi : no shifting dullness
Auskultasi : bowel sound normal
Extremities
CRT<2”, warm lower extremities, no edema

12. LABORATORY FINDING
Jenis Pemeriksaan Reference 07/06/2017
Hemoglobin 12,0-16,0 g/dL 13.7
Hematokrit 37-47 % 39
Eritrosit 4,3-6,0 x 106/L 4.7
Leukosit 4.800-10.800/L 12070
Trombosit 150.000-400.000/L 201000
MCV 80-96 fL 83
MCH 27-32 pg 29
MCHC 32-36 g/dL 35
Malaria rapid Negative negative
CBC from Rumah Sakit Pondok Indah ( 5 June 2017):
Hb 13.5 Hematocryte 38.6 Erytrocyte 4.58 Trombocyte 178000
Diff count 0.8/3/74.4 (segmented neutrophyle)/13.6/8.2
Procalcitonin 0.71

13. LABORATORY FINDING
Jenis Pemeriksaan Reference 07/06/2017
Ureum 20-50 mg/dL 10
Kreatinin 0.5-1.5 mg/dL 0.8
Glukosa Darah (Sewaktu) 70-140 mg/dL 122
CRP Semi Kuantitatif < 6 mg/dL 18
Natrium 135-147 mmol/L 126
Kalium 3.5 – 5.0 mmol/L 4.1
Klorida 95-105 mmol/L 96

14. LABORATORY FINDING
Urinalisis Reference 07/06/2017
Urin lengkap
Warna Kuning Kuning
Kejernihan Jernih Jernih
Berat Jenis 1.000-1.030 1.015
pH 5.0-8.0 7.5
Protein negatif +/pos 1
Glukosa negatif -/negatif
Keton negatif -/negatif
Darah negatif +10(RBC/ul)
Bilirubin negatif -/negatif
Urobilinogen 0.1-1.0 mg/dL 0.1
Nitrit negatif -/negatif
Leukosit esterase negatif -/negatif
Sedimen Urin
Leukosit <5/LPB 1-2-1
Eritrosit <2/LPB 1-1-1

15. LABORATORY FINDING
Urinalisis Reference 07/06/2017
Silinder negatif/LPK -/negatif
Epitel positif +/positif
Kristal negatif -/negatif
Lain-lain -/negatif

16. LABORATORY FINDING
 Abdominal USG (30 May 2017)
 Kesan:
 Hidronefrosis grade IV ec nephrolithiasis kanan (batu pelvic ren kanan)
 Cholelithiasis dan cholesistitis
 Cystitis

17. LABORATORY FINDING
 CT-Scan urology (31 May 2017)
 Kesan :
 Hidronefrosis grade IV kanan dengan ureteropelvocaliectasi ec ureterolithiasis
multiple proksimal kanan dan pelvis renalis kanan serta nephrolithiasis multiple
kanan di calyx minor pole bawah ginjal kanan
 Lymphadenopathy paraaorta, parailiaka kanan dan abdomen kanan-kiri bawah
 Gambaran pleuropneumonia dupleks
 Splenomegali non-spesifik

18. RESUME
 58 year-old-male patient with chief complaint of prolonged fever since 1
month before hospital admission. Patient was treated as typhoid fever.
Patient had lost weight over the course of 1 month due to decreased
appetite.
 Physical examination revealed within normal limit. From laboratory
findings, patient is known to have leukocytosis, increased CRP, and
hyponatremia.
 From abdominal USG and CT-Scan, it is revealed that patient has
hydronephrosis and nephrolithiasis.

19. LIST OF PROBLEMS
1. Fever of unknown origin
2. Type II diabetes mellitus, normoweight, controlled blood sugar
3. Hydronephrosis and nephrolithiasis

20. Problem Assessment Plan of care Plan
1. Fever of
unknown
origin
Based on:
History : prolonged fever for 1
month, never subsided, history
of antibiotic administration for
typhoid fever, weight loss,
decreased appetite
Laboratory finding Leucocyte
12070 , CRP 18, Procalcitonin
0.71,shift-to-the-right diff. count
Target:
- Diagnostic work-
up
Diagnostic :
- Widal test
- Rapid test HIV
- Chest X-ray
Theraphy :
- Paracetamol 3x500mg
- Ceftriaxone 1x1gr
Education :
─ To explain the possible
diagnosis and
differential diagnosis
that might cause the
fever
─ Laboratory assessment
needed to establish
diagnosis
Fever of Unknown Origin
Fever of unknown origin (FUO) identifies a syndrome of
fever that does not resolve spontaneously, in which the cause
remains elusive after an extensive diagnostic workup.
Petersdorf and Beeson first coined the term fever of unknown
origin in 1961 and explicitly defined it as :
(1) Temperature > 38.3ºC (101ºF) on several occasions
(2) duration of fever of more than 3 weeks and
(3) failure to reach to diagnosis despite one week of inpatient

21. FEVER OF UNKNOWN ORIGIN
Roth AR, Basello GM. Approach to the Adult Patient with Fever of the Unknown Origin. AAFP. 2003;68:2223-8.

22. FEVER OF UNKNOWN ORIGIN
Roth AR, Basello GM. Approach to the Adult Patient with Fever of the Unknown Origin. AAFP.
2003;68:2223-8.

23. Roth AR, Basello GM. Approach to the Adult
Patient with Fever of the Unknown Origin. AAFP.
2003;68:2223-8.

24. Problem Assesment Plan of care Plan
2. Type 2
Diabetes Mellitus
Based on:
History :
Diagnosis of diabetes mellitus
in 2017. Patient is known to
take Metformin regularly
Target :
Controlled
blood glucose
Diagnostic:
- KGDH
Therapy :
- Diet DM MB 1700 kkal
- Metformin 2x500 mg
Education:
• Encourage the patient to take
oral antidiabetic agent
regularly
•Diabetic diet
Type 2 diabetes mellitus
Type 2 diabetes mellitus consists of an array of dysfunctions
characterized by hyperglycemia and resulting from the
combination of resistance to insulin action, inadequate insulin
secretion, and excessive or inappropriate glucagon secretion
Diagnostic criteria by the American Diabetes Association
(ADA) include the following :
• A fasting plasma glucose (FPG) level of 126 mg/dL (7.0
mmol/L) or higher, or
• A 2-hour plasma glucose level of 200 mg/dL (11.1 mmol/L)

25. DIAGNOSIS
Konsensus Pengelolaan dan Pencegahan DM tipe 2 di Indonesia. Perkeni. 2015

26. Konsensus Pengelolaan dan Pencegahan DM tipe 2 di Indonesia. Perkeni. 2015
Algoritme PERKENI 2015 Pengelolaan DM Tipe 2
Gejala
(-)
Gejala
(+)
Dualtera
pi
Tripel
Terapi
Insulin
+ obat
lain
MODIFIKASI GAYA HIDUP
HbAIC < 7.5%
3 bulan masih
HbA1C > 7%
Monoterapi
• Metformin
• Agonis GLP-1
• Penghambat DPP-
IV
• Penghambat
glukosidase alfa
• Penghambat
SGLT-2
• Tiazolidindion
• Sulfonilurea
• Glinid
HbAIC ≥ 7.5%
Monoterapi + 3
bulan masih HbA1C
> 7%
Dualterapi
kombinasi
(mekanisme beda)
• Metformin
• Agonis GLP-1
• Penghambat DPP-IV
• Penghambat
glukosidase alfa
• Penghambat SGLT-2
• Tiazolidindion
• Sulfonilurea
• Glinid
• Bromokriptin
Tripelterapi
kombinasi
• Metformin
• Agonis GLP-1
• Penghambat DPP-IV
• Penghambat
glukosidase alfa
• Penghambat SGLT-2
• Tiazolidindion
• Sulfonilurea
• Glinid
• Bromokriptin
• Insulin basal
HbAIC > 9%
Dualterapi + 3 bulan
masih HbA1C > 7%
Jika tripelterapi belum mencapai
sasaran dalam 3 bulan
Tambah insulin
Atau
Intensifikasi insulin

27. CONTROLLED DIABETES MELLITUS
Konsensus Pengelolaan dan Pencegahan DM tipe 2 di Indonesia. Perkeni. 2015
Glukosa pre-prandial (mg/dL) 80 – 130
Glukosa 2 hour post prandial (mg/dL) <180
HbA1c (%) < 7
LDL Cholesterol (mg/dL) < 100
HDL Cholesterol (mg/dL) > 40 (laki-laki)
>50 (perempuan)
Triglyseride (mg/dL) < 150
BMI (kg/m2) 18,5 - <23
Blood Pressure (mmHg) < 140/90

28. Problem Assesment Plan of care Plan
3.
Hydronephrosis
and
Nephrolithiasis
Based on:
History :
No history of flank pain, no
history of hematuria, normal
micturition
Laboratory Finding:
Urinalysis shows RBC on
routine examination
Target :
Urology
assessment
Urology assessment and
follow-up

29. PROGNOSIS
• Ad vitam : dubia
• Ad functionam : Bonam
• Ad sanactionam : Bonam

30. THANK YOU